HomeMy WebLinkAbout1357 (7) - ---_-__. -a ,..- �-;�,.� ' - � .�, __... . , _. . .` . .;, r -- ,
� WORKERS'{OMPENSATIONDECIARATiON 7�iA663 �o�e, . ��APP��c�A'�i9`�N FOR E��C�'i'�AL PERMIT - � ---
1 hereby�offirm that I hove�a ce�tiiicote of consent�o self �"-�� �- �•
insure,or p ce�tificote of Workers'Compenwcon��w�o��e, „ COUNiY OF LOS ANGELES BUILDING AND SAFETY
� or a cerlified copy fhereaf(Sec.3800,Lob.C.) � _ -
' P❑o��iCy Na��Company � - FOR APPLIUNT TO Rll IN � DDRES � �
! Ce ified mpy is he.eby furnished. New Residential Bldqs.8 Pools E�H �� � �p�A11TY
'�, � Certified topy is filed with the munty building inspeo- 1 8 2-Family,Sq.FL E — S
tioo departmenl. Multi-family Sq.Fl. — NfARESi _ �
/%J^����^}r�� � Residentiat Swimming Pools OWNER OR f
�i Daie�„�"pplicont�� FIRMNAME ^ C
CERiIFICATE OF EXEMPTION FROM WORKERS' Ou�lets:Rec� 1 ���
COMPENSATION INSURANCE '���9h}`5"�'— � ADORESS S �
Firs�10 �
t (This�vctlon nad nof b�compb»d il th�werk imolved 6y Total No. Additional CITY Tel.No.
1h�p�rmN is for on�hundnd dollen(5100)or I�s�.) P�AN CHECK
I certify ihot in�he performance of the work for which�his APPLICANT �
permil is issued,I sholl not employ ony person in ony monner �
so os to 6etome subject lo the Workers'Compensolion Laws. ��9hting Fixturas First 20 ADDRE55 �
Totnl No. Additional CITY � Tel.No.
� Da�e opplimnl Fized Appliances Not Over 1 HP pERMIT
�, NOTICE TO APPLICANT: If, after making this Cenificare of APP�ICANT n�
Exemption, you shoold become sobject io �he Workers' Range._Heater�D.W,_
Compensalion provisions of ihe La6a Code,yoo musl farth- O�an _Dryer —W.M._ ADDRESS
i1h comply wiih such provisions or ihis pe�mil shall be 7op _FAU —W.H.— •
deemad revoked. Hood _Fon ,Other_ CI7Y , - Tel.tJo �
LICENSEO CONTRACTORS DECIARATION - LiCEN R
� I hereby offirm thot I om licensed undar provisions of Chopter 9 Disp. _Room Air Cond. �— REG NUMB 3� Class.
, (commencing with Section 7000)of Division 3 oF ihe Bu6iness powar Apparotus 8 Large Appliances . DISTRICT NO. PROCESSED BY �,
ond Pro{assions Code,and my licanu is in full force ond effect � y
,� �-�a /'� �� Size 8 Type HP,KW,KVA,or KVAR O � O
�icense Number.�,��.i�ic.Class_5.1� �p�a 1 Incl. FINAL � V
ConhaUnr �� ��� Date���'S— Over 1 to 10 Incl. DATE yAL�0AT10N Q ,
Over 10 to 50 Ind. FINAL V �
❑ .I om exempt under Sec Over 5010 100 Inc. 8Y . ', �
6.SP.C.for this reason �V°��� t�7 Z
� pa e. Services,Swbd.,MCC 8 Panelboords ►
0-200 Amp.Under 600 V y� #$��
Signature 201-1000 Amp.Under 600 V I U� � '�+•�.� �a rJ�
Over 1000 Amp.or Over 600 V � �� � �
� Exempnon for Reg.Maint.Elec�, t��
SINGLE fAMILY Temp.Power Pola 8 Appur7enances , e 7.�k 3�A=
�. HOME OWNER-BUIL�ER DECLARATION Sign with One Broach Circuit �/ �
, I here6y offirm ihat I am exempt from fhe CoMraUor's Licanse qdditional$ign Bronch Circuits /�- �S
Low for the Iollowing reason($ettion 7031.5,Business and � .
� Professions Code): �
I,as owner af,the properly,will do the work and Ihe M:sc.Conduits 8 Conductors
� structure is no�in�ended or offerad 4or wle(Section O�her(See Complete Fee Schedule)_ ►
7044,Businass pnd Professions Code). . ,
CONSTRUCTION LENOING AGENCY � � - �
I hereby af4irm ihat there is a conslruUion lending agency for
the performance of ihe work for which this parmit is issued PERMIT FEE (Sub•Totat) - � . .
� (Sec.3097,Civ.C.). � _
PLAN CHEGNING FEE . � ..
� Lender's Name � � D �
PERMIT ISSUING FEE � �
. Lender's Addrass . f//j_ `� � ,
� I certify thol I hove read this application and stme thot the TOTAL FEE c�'J �
obove informalion is correct.I ag�ce�o comply wi�h ull Couniy . �
ordinances and S�ate lows regulo�ing EleUritol wiring,ond , '
he�eby auihorize representatives of this County to emer upon . � � -
the above-menrojn�,pwperty for inspectio�purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE '
�t�t-��YrY�"�Z?- �3-�S
Signa/ure of Perminee Dale . '
` ._ — i
-�' ,"....._'� _� . _. __.--- -- _ _. _. _ '
- . - -��:�/ - �'=.` _ __ _ --
;
, j �
- . APPROVAtS - � pATE � - OWNEP,-BUILDER DECIARATION.
SIGN4T .
� TEMP.POV✓ER POLE - 1 hareby affirm that I om exempt from the Coniradcr's
'� - � '� -, UND`.RSLAB WORK � . Litensa Lav+for tho follawing roason (Scction 703i.5,
, Buslness ond Prafesslons CodeJ:Any cRy or county whtcf:
� - ROUGH CONDUIT - -- � requlros o permif fo conslruct,oller,lmprove,demolish,
.. �_ , or repelr.dny s�rvdurc,pAor!o its�lssuance, olso re-
� ' WIRING qulres tho opplicant lorsuch parm�f lo file a signeds�ate-
� � FIXTURES � � . meM that he Is Btensed pvrsuanf fo�ho provlslonz of fho
. Contracror's Lkense iaw(Chapfcr 9(commencing w�th
POWER AUTHORIZED - - Sec�lon 7000)o!0lvlsfon 3 0l the Sus/ness pnd Profes- �
UTIIIN CO.NOTIFIED slons CodeJ or tbaf hc Is exemp/Ihercfrom and Ihe basts
�for !he alleged oxcmp�lon. Any violaflon ol Secllon
fINAL c7 , � 703L5 by any appllcant for a permlf su6�ecfs the oppfi-
�rt�ci on strortE con}fo a clv7f penolfy of nat more thon /ivo hundred
�� NOTES � . _ . doflors(5500).:
� " . _ � � � � , ❑I,ao owner of iha property will do ther work,ond
� � - � �1ha atructure Is not iNended or offered for salo.
� . . . (See.704�,ButlttssrandP�olotsionxCode: ihoConlroo
� " � � � for's llcense Law does nof apply to an owncr of properry
' � � _ .- . . , who 6u!!ds or 7mproves lhereon, and wbo does sucb
-� - - � work hlmeell provlded tho!such lmprovemon�s ore nof
- � � - �� Inf¢ndad or o/lered far sale.N,however,�he bullding or
Improvement is sold wllhln one yevr o/completion,thv
. � , ownen6ul�der wlll havc fhe burden olproNng�haf he did
- " � nof bu!!d or Improve lor Iho purpose o!salv.)
' " - 1 om�exe'mp�under Sec. � ,
� , _.
B&P.C.for this reason �
, e - � . . . , - .
Date
��,. . �,� ; „ � Owner
�/ , . . ._. . .